INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 18, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Family Service and Children's Aid Society was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to maintain a fire drill record which included the exit route used.
The fire drill logs were reviewed on November 18, 2019. The fire drill logs for drills conducted on November 27, 2018 and January 22, 2019 did not have an exit route documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
FSCAS PROGRAM DIRECTOR MET INDIVIDUALLY WILL ALL FIRE DRILL COORDINATORS AND INFORMED THEM WHEN CONDUCTING MONTHLY FIRE DRILLS TO DOCUMENT ALL PERTINENT INFORMATION INCLUDING THE ROUTE USED, TO ROTATE THE VARIOUS EXITS DURING THE DRILLS, NUMBER OF PARTICIPATES IN THE FIRE DRILLS. WE DISCUSSED THE IMPORTANCE OF COMPLETING ALL INFORMATION ON THE FIRE DRILL FORM AND TO CONTINUE CONDUCTING THE FIRE DRILLS ON A MONTHLY BASIS.
THE FIRE DRILL COORDINATORS WILL CONDUCT MONTHLY FIRE DRILLS AND WILL ROTATE THE ROUTE AND EXITS USED AND DOCUMENT ALL THE PERTINATE INFORMATION ON THE FIRE DRILL FORM.
THE COMPLETED FIRE DRILLS WILL BE DOCUMENTED BY THE FIRE DRILL COORDINATOR AND REVIEWED MONTHLY FOR SIX CONSECUTIVE MONTHS AND BI-MONTHLY FOR THE FINAL SIX MONTHS OF THE YEAR. THE D&A PROGRAM DIRECTOR WILL MONITOR AND SIGN OFF ON THE DOCUMENTS FOR CORRECTNESS ALONG WITH THE FIRE DRILL COORDINATOR. |